Leveraging behavioural science to design better asthma health technology
Republished from 2020
Each day in the UK, three people die from an asthma attack. The majority of asthma deaths and admissions could be prevented with improved basic care and better self-management. Health technology, that helps people self-manage their asthma and promotes long-term behaviour change, can become an integral part of the solution to these problems; however, existing asthma tech products have been poorly adopted. Many products have the tendency to adopt a one-size-fits-all approach and demonstrate a lack of understanding about the behavioural needs of the asthma population.
At Asthma + Lung UK, we saw an opportunity to further our knowledge and expertise in this area by kickstarting a behavioural segmentation project that we are working on with the Public Health England Behavioural Insights Team.
Our research aims to generate improved understanding about asthma self-management behaviours (e.g., adherence, self-monitoring, and healthcare usage) to identify potential areas of unmet need where health technology could offer scalable and effective solutions. The final outputs will underpin the design and development of new digital health products and services in association with the recently released multi-million-pound asthma health technology fund.
We recognise this work is exploratory and so we will openly be sharing our findings as the project progresses. We want to invite you to build on this knowledge and dig deeper into the needs of people with asthma, contributing to the development of behaviour-based technologies that will improve asthma self-management and adherence to treatment to prevent asthma attacks and asthma deaths.
In this blog we share our findings from the preliminary work we have done, which includes systems mapping across the asthma population, and a behavioural analysis of academic literature coupled with insights from the team at Asthma +Lung UK.
Key terms and asthma facts:
Asthma is a common condition – 1 in 11 people in the UK – that can affect people of all ages with varying degrees of severity across their lifetimes. The symptoms of shortness of breath, wheezing and coughing are caused by inflammation in the lungs that causes the airways to narrow, like breathing through a straw. This means you can’t get air in and out effectively and, if not treated, results in severe asthma attacks – medical emergencies – that can be fatal. The majority of routine asthma care takes place in primary care, but asthma attacks often require A&E or hospital admission to get symptoms under control.
Reliever inhalers relieve immediate symptoms when they occur. These are often blue. However, they only work temporarily and do not address the underlying problem that causes the symptoms in the first place which is inflammation in the lungs. They should be used when someone is experiencing symptoms and needs immediate relief but regular use is often a sign of uncontrolled asthma.
Preventer inhalers prevent inflammation and swelling in the airways and stop symptoms developing (preventer inhalers). They should be used regularly (daily – as prescribed by a health care professional) to keep the inflammation dampened down.
Some people have a combination inhaler that does both (relieve and prevent) but for the purpose of this blog we will focus on the behaviours relating to the more common reliever and preventer inhalers.
Reliever inhaler
Many individuals experience an immediate reduction in their asthma symptoms when using a reliever inhaler. Breathlessness is often an unpleasant and distressing experience which may explain why some refer to reliever inhalers as being a ‘life saver’.
If an individual repeatedly experiences immediate symptom relief from using their reliever, they develop a strong physical and emotional association between the use of the reliever inhaler and the reduction of symptoms. This encourages an over-reliance on the reliever inhaler and creates a reinforcing effect, explaining why some individuals become more dependent on their reliever inhaler more over time.
What does this mean for asthma health tech?
Ensuring that reliever inhalers are being used correctly as prescribed (e.g., detecting when someone is over-reliant on a reliever inhaler as an indication of risk of a future attack). Improving knowledge and skills about reliever or a preventer use does not automatically guarantee correct adherence, future solutions need to consider the emotional attachment of reliever use and factor this into product design.
Preventer inhaler
Unlike the reliever inhaler, preventer inhalers do not provide the same amount of immediate symptom relief. The positive effects of a preventer are typically delayed, more ‘invisible’, and only noticeable after a long period of use (at least 3 weeks). This can create a temporary negative effect / feedback loop, when people start taking the medication but do not get immediate feedback (e.g. improvement of their symptoms) so it reduces the belief in the efficacy of the preventor inhaler.
Having the anticipation of a reward (e.g., symptom relief) that provides immediate gratification is one important factor in establishing habitual routines. Therefore, the delayed effect of the benefits / reduction in symptoms with a preventer is a key contributing factor for their lack of prioritisation and low adherence rates in asthma self-management.
Regular preventer use over time will cause an improvement in asthma symptoms, which would in turn positively affect an individual’s emotional attachment to their inhaler and increase their perceived beliefs about its benefits.
What does this mean for asthma health tech?
More thought needs to be given towards reframing the use of preventer inhalers, demonstrating their value and helping people recognise the ‘invisible’ benefits. We would love to see more products designed that help activate a positive reinforcement loop, which rarely happens due to the delay in seeing the preventer make a difference.
Preventer vs. reliever relationship
As the use of preventer inhalers decrease, eventually individuals are likely to experience an increase in the severity and/or frequency of their asthma symptoms. As the symptoms increase, individuals are likely to turn to their reliever inhaler because they can’t see the benefit of their preventer inhaler. This experience of immediate relief may further strengthen their attachment to their reliever, especially if symptom reduction is interpreted to mean that their asthma is no longer present. This leads these individuals into a repeated cycle of experiencing worsening of asthma symptoms and relying on their reliever inhaler to manage these symptoms over time.
What does this mean for asthma health tech?
The development of asthma tech for improving adherence to preventor and reliever inhalers have traditionally adopted a one-size-fits-all model in designing solutions for inhaler adherence (e.g., reminders) and treating adherence for both inhaler types as the same behaviour. However, the behavioural needs of using a preventor and reliever inhaler are significantly different and needed to be treated as different interventions.
Engaging with healthcare services
Getting help
There is often an assumption that providing information about asthma leads to improved recognition of symptoms and more regular healthcare interactions. However, knowledge alone does not always lead to taking action. People with asthma need more than just information and reminders to regularly attend GP appointments and annual reviews.
If the advice from a healthcare professional results in an improvement in symptoms, the quality of advice is perceived to be high, and individuals are more likely to follow future advice and engage in self-management behaviours outside of GP appointments. The strength of relationship between the healthcare professional and patient is also a big factor in determining the regularity and quality of interaction with healthcare services. When a person with asthma’s symptoms improve, they are more likely to view their asthma as controlled and less likely to seek help from their GP.
It is important but often hard for many individuals to identify when their asthma symptoms are severe and they need to engage with healthcare services – both GP and urgent care. Our previous research has shown that some people with asthma are poor perceivers (e.g., they think their asthma is better controlled than it is), which can lead to them not getting the right help or accessing services early enough. If an individual can recognise their symptoms as being asthma-related, they are more likely to seek help; however, there are currently a lack of tools to help people to do this.
Diagnosis and treatment
Asthma treatments are currently optimised through trial and error, which means people are given different inhalers to try, to see what works for their type of asthma. Consequently, people with asthma can spend long periods of time relying on ineffective treatments, a contributing factor to poor adherence and the lack of trust in using the preventer inhaler. Improving diagnosis and treatment plans will ensure that patients get the right inhaler which will improve their overall quality of care and quality of life.
What does this mean for asthma health tech?
Improving digital diagnostic tools can create better links between the type of symptom and the action needed (e.g., seeking emergency care if symptoms worsen). People need help prioritising their asthma management coupled with more support, accountability, and encouragement along the way.
Improved monitoring and diagnosis of asthma symptoms would ensure that annual reviews and GP visits are in response to symptom flare-ups, rather than at an arbitrary time of the year.
Self-monitoring: identifying asthma symptoms and triggers
Being able to reliably identify asthma symptoms and triggers helps people to identify and avoid triggers and can help to improve an individuals’ understanding of their condition. Given that the frequency and severity of symptoms are central to a number of the feedback loops we’ve already discussed, being able to accurately and objectively recognise the frequency and severity of symptoms can significantly influence self-management behaviours like adherence.
The deferred consequences of both the disease (asthma is episodic, so people can go long periods without symptoms / attacks) and the inhaler (because it takes time to work) is why extensive behaviour change is needed in asthma. However, there is a lack of self-monitoring tools to facilitate this. For example, being able to see the positive effect of an intervention on lung function (e.g. preventer inhaler improving lung function) helps to reinforce the self-management behaviour (e.g. adherence to preventer inhaler), potentially even mitigating the delayed impact of the medication on symptoms. The contrary is also true, demonstrating the negative effect of unhealthy lifestyle behaviours (e.g. smoking) on symptoms and lung function could help people to stop this behaviour that is negatively impacting on their asthma. The immediate feedback is key – yet there are very limited tools that do this.
What does this mean for asthma health tech?
We need the development of objective self-monitoring tools that help people establish a personal baseline, monitor the frequency and severity of symptoms and reinforce key self-management behaviours. The data collection from these tools will need to be passive – from previous research we know that solutions that require extensive data input from people with asthma often don’t work, especially for those at most risk. People will need to perceive the value / benefit to be greater than the time they have invested. The data also needs to be timely, actionable and lead to a personalised intervention to improve asthma management based on this information. Data for data’s sake is not very useful.
Many people with asthma do not want to constantly acknowledge their asthma (like people with many other long-term conditions) and continually monitor it. There is significant potential in leveraging consumer technology that helps people manage their asthma but isn't asthma specific and seamlessly incorporates into people’s everyday lives.
Conclusion
Designers, developers and researchers should take into account the asthma self-management behaviours and their accompanying influences explored in this article when developing future health technology. Without this, products will continue to fall short of meeting people with asthma’s needs and will be poorly adopted.
We would encourage applications to our multi million pound Asthma Health Technology fund to support the development and adoption of scalable, user-centred and evidence-based tools for the diagnosis, monitoring or management of asthma. We hope that successful applicants will place behavioural science at the heart of their solution, enabling long-term improvements to asthma outcomes.
